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Chapter
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15
Figure 15.9 2.5× magnification Heine HR® loupe on a S-frame. (Courtesy of
Delasco Dermatologic Lab and Supply, Inc., Council Bluffs, Iowa.)
Setting Up a Sclerotherapy Practice
Figure 15.10 Keeler 2.5× panoramic loupes. (Courtesy of Keeler Instruments, Inc.,
Broomall, Pa.)
has a field size of 9.4 cm and a working distance of 42 cm. A
3× magnifier is available with a working distance of 34 cm and
a field size of 6.2 cm or with a working distance of 50 cm
and a field size of 7.6 cm.
Orascoptic Research, (Madison, Wis.) has a wide-field
loupe of outstanding quality available in 2×, 2.35×, 2.6×, and
3.25× power (Fig. 15.11). There is no distortion across the
entire field of view. The field of view is approximately 124 mm
for the 2×, 88 mm for the 2.35×, 100 mm for the 2.6×, and
50 mm for the 3.25× loupes. These loupes are ergonomically
designed with a downward sightline that can be adjusted to
the exact angle that is most useful and comfortable for the
physician, allowing a more upright posture, which reduces
back and neck strain. The working distance for the 2.0× model
is 12 to 17 inches (30 to 43 cm). A long-range option is available for persons over 6 ft tall (183 cm) and works in the
seated position. The 2.0× model provides a working distance
here of 15 to 21 inches (38 to 53 cm). For those who require
a longer working distance, an extra-long range is available as
well. The 2.0× model has a range of 17 to 23 inches (43 to
58 cm).
A flip-up design with autoclavable handpiece makes changing from normal to magnified viewing easy. The lightweight
frames come in two sizes with detachable side shields. The
2.6× loupes are ideal for sclerotherapy and dermatologic
surgery.
Figure 15.11 Orascoptic telescope shown with optional side shields and
flip-grip autoclavable handle. (Courtesy of Orascoptic Research, Inc., Madison, Wis.)
Fig 15.12 SurgiTel loupes with micro-mini fiberoptic light. (Courtesy of General
Scientific Corporation, Ann Arbor, Mich.)
The SurgiTel loupe from General Scientific Corporation
(Ann Arbor, Mich.) is similar to the Orascoptic loupe. It is
available in 2.15×, 2.75×, 3.5×, and 5× power. It also has five
adjustments to optimize the viewing angle. The lightweight
frames come in two sizes with available side shields. The
2.75× loupe (most useful for sclerotherapy) has a field of view
of 58 to 106 mm with a working distance of 250 to 404 mm
or a 66- to 136-mm field of view with a 312- to 553-mm
working distance, depending on the model type. These loupes
also come with a fiberoptic light source that is small and wellbalanced (Fig. 15.12).
As with the Orascoptic loupes, a flip paddle is available to
ensure sterility in flipping the magnifying lenses out of the
field of view. The SurgiTel System also has available a wide
assortment of clip-on optical filters for use with virtually any
wavelength during laser surgery.
Other, less expensive models include the N1064 Oculus
loupe (Orascoptic) (Fig. 15.13). Another, the Westco 2× to
2.5× adjustable loupe, is also less expensive and of excellent
quality. The lens-to-object working distance is 13 cm with a
3-cm field of view at 2.5×.
The lowest-priced loupe of high quality is the See Better
(Edroy Products) loupe. The magnification is 2.5× with a field
of view of 9 cm and an eye-to-working distance of 35 cm.
Polarizing magnification
The ability to see an object depends on the light reflected from
it. Reflected light is a combination of light reflected at the
surface of the object and light back-scattered from the inside
of the object. Surface quality, shape, and roughness are contained in the surface reflectance component. The back-scattered
384
Figure 15.13 N1064 Oculus loupe. (Courtesy of Oculus Inc, Lynnwood, WA)
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Figure 15.14 Syris v600 Vision Enhancement System. (Courtesy of Syris
Scientific LLC, Gray, Me.)
component within the object determines the ability to see the
object’s color. Polarization separates the view of surfacereflected light from back-scattered light. Glare-free viewing
permits one to see subsurface features, such as the needle
within the vessel.
Syris Scientific (Gray, Me., USA) makes a vision enhancement system consisting of headband-mounted simple binocular magnifiers that expand the use of this low-cost magnification
device with the incorporation of a dual polarizing system
(Fig. 15.14). The use of polarization eliminates reflected light
to enhance the appearance of vascular structures on the skin
(Fig. 15.15). The tungsten-halogen light source is cooled with
a microfan and has an operating lifetime of more than 400
hours.
SurgiTel loupes also offer polarization with the attachment
of a micro-mini fiberoptic light fitted with a polarizing
cover. The loupes are then fitted with polarizing filter caps
(Fig. 15.16).
Transillumination
The Venoscope transilluminator (Applied Biotech Products,
Lafayette, La.) assists in locating and visualizing vessels 1 to
2 mm below the skin. Dual fiberoptic light guides shine light
from krypton lamps though adjustable fiberoptic arms. This
device is most useful to mark veins in the surgical supine position before ambulatory phlebectomy and may also be useful
in visualizing feeding reticular veins (Fig. 15.17A). A newer
model is lighter and comes available with disposable plastic
covers (Fig. 15.17B).
The Veinlite (TransLite LLC) is a second transillumination
device for imaging reticular and telangiectatic leg veins. It has
a large ring 150-W illuminator lighting system powered
through a 6-foot-long fiberoptic cable. The ring has an outer
diameter of 62 mm and an inner open diameter of 36 mm.
The light output can be adjusted by a rheostat (Fig. 15.18A).
A smaller model, the Veinlite LED, has a C-shaped design with
side-illumination in 12, two-color light emitting diodes
(LEDs) of orange and red to allow visualization of veins
through any skin color (Fig. 15.18B). It also comes with disposable plastic covers. A newer model, the Veinlite II, has an
additional high-contrast filter to more clearly highlight superficial veins. Alternately, its white light setting allows for detection of deeper varicose veins. The Veinlite II also comes with
disposable covers, as well as an autoclavable ring.
Sam’s Light (Wagner Medical; Middlebourne, W.Va.), a
150 W venous transilluminator, utilizes a faster power source,
as well as an improved fiber optic cable, which allows excellent visualization of the venous network. This device allows
the practitioner to detect ‘hidden’ reticular veins with ease,
thus increasing accuracy and decreasing the time necessary to
perform sclerotherapy cases.
Intermedic S.A. in Spain manufactures the TRANSivein
transilluminator. This elegant device illuminates the superficial veins with a ‘U’-shaped halogen light certified to 2000
hours. The opening of the ‘U’ is 35 mm, allowing easy insertion of a needle and syringe.
The VeinViewer (Fig. 15.19), patented by Luminetx Corporation of Memphis, Tenn, provides an innovative approach to
visualization of subcutaneous veins. The device, which was
introduced in 2005 and began to be distributed in 2006,
makes subcutaneous, reticular veins visible by projecting realtime images of the exact location of veins directly onto the
skin. The VeinViewer uses a near infrared light source to image
the hemoglobin in red blood cells, allowing a video camera
to capture the images. The video images are processed through
a computer and the venous images are projected onto the
patient’s skin within 0.06 mm of their exact location. The
sclerotherapist can quickly and accurately map the veins
which feed cutaneous blemishes and then proceed to definitive and accurate therapy using foam or liquid.
The VeinViewer is particularly useful in treating the veins
that feed cartwheel blemishes of the lateral thigh. It visualizes
the progress of sclerosant through the veins during treatment
of telangiectasias, verifying that proper treatment has been
accomplished.
Endovenous ablation systems
Initially, the practitioner wishing to begin incorporating leg
vein procedures into his/her treatment armamentarium
should invest in a single modality for endovenous thermal
ablation (radiofrequency or laser). As the practice grows, the
sclerotherapist should consider providing patients with the
full spectrum of treatment modalities for superficial vein
reflux disease (i.e. radiofrequency, endovenous laser ablation,
and ultrasound-guided foam sclerotherapy).
18
Table 15.2 lists
Equipment
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Setting Up a Sclerotherapy Practice
A
Figure 15.15 A, Appearance of leg veins without polarization. B, Appearance of leg veins with polarization. (Courtesy of Syris Scientific LLC, Gray, Me.)
B
endovenous thermal ablation systems currently approved by
the Food and Drug Administration.
Phlebectomy instruments
While the ambulatory phlebectomy technique is discussed
elsewhere in this text (Chapter 10), this section will focus on
the surgical instruments necessary to perform the procedure.
At the very least, a practitioner performing ambulatory phlebectomy should have the following instruments on his/her
surgical tray: a vein hook (Mueller, Goldman-Kabnick, Oesch,
Ramelet, or Varady types), at least two sets of curved venous
forceps, iris scissors, and an 11-blade. A blunt probe is also
necessary to free the veins from the surrounding fascial attachments. Wagner Medical offers a wide array of vein hooks and
venous forceps, including a newer venous forcep designed
with elongated teeth, which promotes a more secure grip
on veins.
Foam pads
Foam compression pads (Fig. 15.20) are manufactured from
white latex rubber. They are beveled to produce maximum
Polarizing
filter caps
Figure 15.16 SurgiTel loupes with micro-mini fiberoptic light with
polarizing filter caps. (Courtesy of General Scientific Corporation, Ann Arbor, Mich.)
compression along the line of the injected vein segment. STD
Pharmaceutical distributes two sizes of pads useful for providing additional compression over varicose veins (see Chapter
6): D pad (5 cm ×13 cm × 2.5 cm high) and E pad (4 cm
×13 cm × 1.75 cm high).
Tape dressings
To support the placement of foam pads with minimal pressure, three sizes of Microfoam (3M, St Paul, Minn.) surgical
tape are recommended: size D, 7.5-cm diameter (for lower
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15
Setting Up a Sclerotherapy Practice
legs); size E, 8.75-cm diameter (for lower legs or small thighs);
and size F, 10-cm diameter (for thighs).
To support the placement of pads or to apply additional
localized pressure, Coban tape (3M) or Medi-Rip (Conco
Medical Co., Rock Hill, S.C.) bandages are recommended. The
Medi-Rip Bandage is a cohesive, tearable, elastic bandage
rolled in 1-inch tubes. It is available in 1-, 2-, 3-, 4-, and 6-inch
widths and is composed of 99.2% cotton and 0.8% polyurethane with a latex cohesive finish. The cotton-covered
rubber threads minimize constriction and control elasticity.
The microfine cohesive cover allows it to stick to itself instead
of to hair or skin and eliminates slippage.
Graduated compression stockings
Information about graduated compression stockings can be
found in Chapter 6 and online in Appendix A. One useful aid
to help support the thigh stocking in the proper position on
the leg is a body adhesive called ‘It Stays!’ (Beiersdorf-Jobst,
Charlotte, N.C.). This body adhesive comes in a roll-on bottle;
it does not dry on the skin, and it remains tacky until it comes
in contact with water. The product is nontoxic and nonflammable and only rarely causes skin irritation.
Another useful device to support vulvar varicosities is
the V2 Supporter (Prenatal Cradle Inc., Hamburg, Mich.)
(Fig. 15.21) (see Chapter 6).
Antiseptic
Alcohol-soaked cotton balls are liberally applied to the telangiectatic area before injection to cleanse the area of bacteria
and applied oils and grime. This also improves the refraction
of light to enhance the appearance of the vessels. The addition
of 5% acetic acid (white vinegar) to the alcohol solution may
aid visualization but has not been found useful in our
practice.
Photography
Figure 15.19 VeinViewer. (Image courtesy of Diomed Inc., Andover, Mass. VeinViewer
is a registered trademark of Luminetx Inc., Memphis, Tenn.)
Table 15.2 Endovenous thermal ablation systems currently approved by the United States’ Food and Drug Administration*
Year Model Manufacturer Type Web Site
1999 VNUS Closure (Plus) VNUS Med Tech, Sunnyvale, Calif. RFA www.vnus.com
2002 EVLT Diomed, Andover, Mass. EVLA www.diomedinc.com
2002 ELVeS Biolitec Inc, East Longmeadow, Mass. EVLA www.biolitec.com
2002 VenaCure AngioDynamics, Queensbury, N.Y. EVLA www.angiodynamics.com
2003 Medilas D C Diode Dornier, Germering, Germany EVLA www.dornier.com
2003 Vari-Lase Vascular Solutions, Minneapolis, Minn. EVLA www.vascularsolutions.com
2005 CTEV CoolTouch, Roseville, Calif. EVLA www.cooltouch.com
2007 VNUS Closure (Fast) VNUS Med Tech, Sunnyvale, Calif. RFSA www.vnus.com
EVLA, Endovenous laser ablation; RFA, radiofrequency ablation; RFSA, radiofrequency segmental ablation
*Adapted from: Shortell CK and Markovic JN: Incorporating outpatient venous procedures into a vascular surgery practice, J Vasc Surg 50: 225, 2009.
Photographic documentation is recommended when treating
any patient with varicose or telangiectatic leg veins. Not only
Figure 15.20 Foam compression pad.
388
‘through-the-lens’ (TTL) setting. Kodachrome ASA 25 or 64
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film gives the highest quality reproductions.
Digital cameras are now available that provide outstanding
quality at an affordable price. They also offer the advantage of
viewing the image immediately after it is taken to ensure
proper exposure. The disk can be stored in the patient’s chart
for easy access, and all images can be logged and stored on a
computer for easy file and retrieval applications. A complete
discussion on the available models and types of digital cameras
is beyond the scope of this text. In addition, the information
becomes outdated so quickly that readers are encouraged to
visit various photography websites to choose the digital
camera that best suits their needs. My favorite camera at the
time of this writing is the Exilim (EX-Z50) 5.0 megapixels by
Casio. It is small enough to fit in your pocket for easy access
and takes excellent quality photographs. The 3× optical Pentax
zoom lens can take outstanding close-up photographs as well
as full-leg views.
Rocha et al evaluated the use of digital photography in
combination with a computer program to assess the degree of
clearance of telangiectasias during sclerotherapy treatment.
Photographs were taken using a digital camera (Olympus
D-600 L, Olympus Imaging America Inc., Melville, N.Y.) with
a resolution of 1280 × 1024 pixels. Before and after images
were subsequently analyzed by two methods, the first being
an analysis of projected images by physicians with sclerotherapy experience, and the second being an analysis of images
by a computer program designed at the Electrical Engineering
and Computation University of Campinas, Brazil. This computer program allowed automatic detection of telangiectasias,
quantifying them by color and morphology, and using pixel
computations to calculate the percentage of telangiectasia in
the pre-and post-treatment images. The program then computed the percentage variation in telangiectasias between the
two photographs. Computer clearance rates showed a statistically significant correlation with those made via physician
assessments, which supports the potential value of this computer program.
19
Insurance Reimbursement
Figure 15.21 V2 supporter. (Courtesy of Prenatal Cradle, Inc., Hamburg, Mich.)
do many insurance companies require photographic documentation before approving reimbursement, but also patients
often cannot remember later exactly how their leg veins
appeared initially. In addition, because varicose telangiectatic
leg veins may continue to appear throughout a patient’s lifetime, documentation of treated areas will help distinguish
between new veins and recurrent veins. Finally, some patients
with longstanding varicose veins have hyperpigmentation
around the varicosity. Preoperative photographic documentation is thus important (see Chapters 9 and 12).
Ideally, all photographs should be taken with the same
camera, type of film and processing, lighting, F-stop and
shutter speed, distance, as well as angle of exposure from the
camera to the patient. For non-digital cameras, we recommend using a Nikon 2020 fully automatic camera (Nikon,
Melville, N.Y.) fitted with a Nikon 105-mm macro lens and
Sunpak auto 444D Thyristor flash. It is beneficial to replace
the factory ‘split-image’ internal lens with a clear lens to aid
in close-up focusing. All photographs are taken at standard
F-stops: F16 for close up, F11 for half-leg view photos, and F8
for full-leg vein photos. Photographs are taken at an automatic
Patient Informational Brochures
To educate patients about sclerotherapy, it is best for the
physician to produce a brochure or information sheet that
incorporates his or her unique and personalized approach to
such treatment. There is no totally right way to perform
sclerotherapy, and there are relatively few absolutes regarding preoperative preparation, treatment, and postoperative
instructions. However, to produce personalized brochures is
expensive. As an alternative, a number of ready-made commercial brochures are available (see online Appendix D). One
particularly valuable patient education pamphlet that provides information on the etiology as well as the treatment of
varicose and spider veins is available through the American
College of Phlebology.
20
Insurance Reimbursement
Many physicians have expressed frustration in their attempt
to obtain insurance reimbursement for the treatment of varicose veins with compression sclerotherapy, even though the
veins are symptomatic. Coverage is usually limited to patients
who have complications that can be attributed to their underlying venous disease. For example, patients with lifestylealtering symptomatic venous disease which does not respond
to conservative therapy as well as those with concommitant
phlebitis, ulceration, or cellulitis are more likely to have insurance that covers varicose vein treatment then those who are
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Setting Up a Sclerotherapy Practice
390
asymptomatic. However, even those with symptomatic venous
disease can experience trouble obtaining treatment reimbursement from insurance companies until they fail a trial of conservative therapy (extremity elevation, daily use of compression
stockings, and exercise for 3 to 6 months).
12
From a limited
review of insurance reimbursement in our practice, the amount
of reimbursement varies markedly, not only between different
insurance companies but also within the same insurance
company from patient to patient, as well as for the same
patient from one treatment to the next. The reimbursement
problem has become so illogical and costly that we have not
billed insurance companies for treatment since 1992. In 2008,
the Centers for Medicare & Medicaid Services (CMS) released
a new Medicare Physician Fee Schedule (MPFA), which
resulted in decreased Medicare reimbursement for vein procedures performed in the non-facility setting.
21
Specifically,
Medicare reimbursement for vascular ablation as well as sclerotherapy fell by almost 15% and 5%, respectively. For the
most up-to-date Medicare fee schedule information, the reader
is encouraged to visit the CMS website at www.cms.hhs.gov/
PhysicianFeeSched/PFSFRN/list.asp.
Patients are told in advance of our office policy not to
accept insurance reimbursement and are advised to obtain
preapproval before they proceed with treatment if they wish
to bill insurance companies on their own. Patients are also
informed that we are not ‘providers’ for their medical insurance company and thus not bound by their reimbursement
rates. However, preapproval usually is in the form of a statement that the procedure will be reimbursed at fees ‘reasonable
and customary’ as determined by the individual insurance
company. We have yet to be able to determine the logic used
to define ‘reasonable and customary’. The wide-ranging variations reflect the enigma of insurance reimbursement for sclerotherapy of varicose veins. Reimbursement of primarily
cosmetic or symptomatic spider telangiectasias or venulectases
is even more of an enigma. Unfortunately, reimbursement for
treatment of spider veins is made worse by the actions of
many physicians.
Most physicians do not submit bills for insurance reimbursement charges for treating purely cosmetic veins. However,
some of my colleagues correctly point out that what is perceived as cosmetic by the patient is in reality a normalization
of cutaneous blood flow and thus, strictly speaking, not cosmetic. In addition, many providers use CPT codes in the
17000 series, indicating destruction of benign lesions for this
treatment. Although one may be able to defend this practice,
we believe using the 17000 codes only serves to further
confuse representatives of insurance companies and may
result in furthering a distrust between the insurance carrier
and the sclerotherapist. It is our belief that those who perform
sclerotherapy should use the sclerotherapy code; when reimbursement is less than adequate, the insurance claim should
be petitioned and the company should be properly educated
about the cost-effectiveness of sclerotherapy. With this direction, the NASP (now ACP) produced a ‘White Paper’ on sclerotherapy that was sent to more than 600 insurance carriers
in 1992.
22
This paper was produced as an aid to the physician
when submitting bills for reimbursement and to educate the
insurance company. It defines phlebology, sclerotherapy,
and surgical treatments, discusses symptomatology and the
medical necessity for treatment of the defined disease, and
concludes with guidelines for determination of medical necessity. Not one insurance company representative responded to
this document even after numerous follow-up letters.
Many methods have been used by practitioners to educate
insurance companies on the technique of compression sclerotherapy. Some of us send the insurance companies detailed
operative reports with or without summaries of the history of
compression sclerotherapy and the cost-effective nature of this
treatment versus surgical ligation and strippings. However,
Box 15.1
Diagnosis (ICD-9) and procedure (CPT) codes for various
sclerotherapy services*
Diagnostic
Spider veins 448.1
Elective/cosmetic procedure V50.1
Varicose veins 454.9
Varicose vein with inflammation 454.1
Leg pain 729.5
Leg edema 782.3
Leg ulcer, chronic 707.1
Chronic venous insufficiency 459.81
Thrombophlebitis, leg 451.2
Hematoma complicating a procedure 998.12
Lymphedema 457.1
Noninvasive testing
Doppler venous – unilateral 93965
Doppler venous – bilateral 93965-50
Doppler arterial 93922
Duplex examination – unilateral or limited 93971
Duplex examination – bilateral, complete 93970
Photoplethysmography – unilateral 93965
Photoplethysmography – bilateral 93965-50
Sclerotherapy treatment
Cosmetic procedure A9370
Spider – face 36469
Spider – non-face 36468
Varicose vein – single unilateral 36470
Varicose vein – single bilateral 35470-50
Varicose vein – multiple unilateral 35471
Varicose vein – multiple bilateral 35471-50
Endovenous ablation (radiofrequency) of
incompetent vein, extremity; first vein treated
Endovenous ablation of second and subsequent
veins in single extremity
Endovenous ablation (laser) of incompetent vein,
extremity; first vein treated
Endovenous ablation of second and subsequent
veins in single extremity
Sclerotherapy tray A4550
Sodium tetradecyl sulfate J3490
Compression bandages A4460
Compression stockings – knee high A4500
Compression stockings – thigh high A4495
Puncture aspiration of hematoma 10160
*ICD-9 codes from International Statistical Classification of Diseases and Related
Health Problems; CPT, Current Procedural Terminology codes from the AMA.
36475
+36476
36478
+36479
this attempt, despite being time consuming for the physician, is often met with indifference on the part of insurance
companies. Thus, each physician must make an individual
decision regarding insurance reimbursement. Box 15.1 lists
insurance codes for various diagnostic, testing, and treatment
services in sclerotherapy.
A detailed discussion of insurance reimbursement for
endovenous treatment of truncal veins is found online in
Appendix H.
Additional Resources
Lastly, there are many companies that offer the new physician
help in setting up a vein practice. One particularly useful
company is Vascular Solutions, Inc. While this is not an
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endorsement for this company, it does provide a very useful
website, insurance reimbursement information, newsletters,
and brochures. Another company, Sclero Tech Consulting,
offers an on-site consultant to train practitioners in clinical
techniques including traditional sclerotherapy, ultrasoundguided sclerotherapy, ambulatory phlebectomy, and duplex
evaluation of the venous system. The consultant is also able
to assist a practice in setting up a system to obtain optimal
insurance reimbursement for vascular procedures.
References
1. Butie A, Goldman MP. Preliminary
results from the North American
Society of Phlebology membership
questionnaire. Newsletter North Am
Soc Phlebol 1988;2:3.
2. Food and Drug Administration:
Communication under the Freedom of
Information Act, 1990.
3. Marston WA, Brabham VW, Mendes R,
et al. The importance of deep venous
reflux velocity as a determinant of
outcome in patients with combined
superficial and deep venous reflux
treated with endovenous saphenous
ablation. J Vasc Surg 2008;48:400.
4. Van den Bos R, Arends L, Kockaert M,
et al. Endovenous therapies of lower
extremity varicosities: a meta-analysis.
J Vasc Surg 2009;49:230.
5. Hallgren R, Fry PD, Goldman MP. The
current and future role of the nurse in
phlebology: the Canadian experience.
Dermatol Nurs 1993;5:60.
6. GE Healthcare, Society for Vascular
Ultrasound, American College of
Phlebology. Lower extremity superficial
venous exam DVD. GE Healthcare in
conjunction with Society for Vascular
Ultrasound and American College of
Phlebology, Wauwatosa, Wis. 2009
(www.svunet.org).
7. Bergan JJ, Cheng V. Foam sclerotherapy:
a textbook. London, UK: Royal Society
of Medicine Press; 2008.
8. Goldman MP, Georgiev M, Ricci S.
Ambulatory phlebectomy: a practical
guide for treating varicose veins. 2nd
ed. Boca Raton, Fla: Taylor & Francis;
2005.
9. Weiss RA, Feied CF, Weiss MA. Vein
diagnosis and treatment: a
comprehensive approach. New York:
McGraw-Hill; 2001.
10. Zwiebel W, Pellerito J. Introduction to
vascular ultrasonography. 5th ed.
Philadelphia: Elsevier Saunders; 2005.
11. Passman MA, Dattilo JB, Guzman RJ,
et al. Impact on physician workload
and revenue following the creation of a
specialty vein clinic within an academic
vascular practice. Phlebology 2007;22:
70.
12. Shortell CK, Markovic JN.
Incorporating outpatient venous
procedures into a vascular surgery
practice. J Vasc Surg 2009;50:225.
13. Labropoulos N, Leon LR Jr. Duplex
evaluation of venous insufficiency.
Semin Vasc Surg 2005;18:5.
14. Epstein E. Magnifiers in dermatology: a
personal survey. J Am Acad Dermatol
1985;13:687.
References
15. Rucker M, Beattie C, McGregor C, et al.
Declination angle and its role in
selecting surgical telescopes. J Am Acad
Dermatol 1999;130:1096.
16. Chaffin DB. Localized muscle fatigue:
definition and measurement. J Occup
Med 1973;15:346.
17. Siegel DM. The precision binocular
loupe. J Dermatol Surg Oncol
1989;15:388.
18. Ganguli S, Tham JC, Janne d’Orthee
BM. Establishing an outpatient clinic
for minimally invasive vein care. Am J
Roentgenol 2007;188.
19. Rocha EF, Filho JP, Alencar RDE, et al.
Quantitative analysis of sclerotherapy
results by using digital photography
and a computer program. Dermatol
Surg 2006;32:902.
20. American College of Phlebology.
Treatment of varicose and spider veins.
San Leandro, Calif.: American College
of Phlebology; 2008.
21. Hickey J. 2009 Medicare fee schedules.
Endovenous Laser Reimbursement
News 2008;8:3.
22. Weiss RA, Haegle CR, RaymondMartimbeau P. Insurance Advisory
Committee report. J Dermatol Surg
Oncol 1992;18:609.
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Introduction
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Introduction
A significant percentage of the species Homo sapiens is known
to develop varicose veins, whereas the condition is rare in
four-legged animals (Fig. A).
is of significant importance in the development of varicose
veins. Why, then, do other erect species fail to develop them?
The answer is probably related to anatomic differences. Taller
mammals, such as giraffes and those that walk upright like
humans, have relatively thick fascial layers enclosing the deep
venous system; humans and shorter mammals, such as rabbits
and rats, do not.
2
Physiologic studies demonstrate that giraffe
capillaries are highly impermeable to plasma proteins. In
addition, their tight skin and fascial layers provide a functional ‘antigravity suit’ to prevent venous hypertension.
Finally, a prominent lymphatic system and precapillary vasoconstriction propel blood and lymphatic fluid against gravity.
Therefore, with a disturbance in this complex system, in
humans, the transmission of high venous pressure to superficial veins, which are not designed to contain that pressure,
results in dilatation; that is, varicose veins. So the development of varicose veins is but one manifestation of ‘venous
insufficiency’.
As discussed in detail later in this introduction and in
Chapter 2, varicose veins should be thought of as one clinical
manifestation of venous hypertension. This, when chronic,
causes a sequence of cutaneous complications: edema, cutaneous pigmentation, venous/stasis dermatitis, atrophie blanche,
cutaneous ulceration and malignant degeneration. Varicose
veins alone may also be complicated by hemorrhage, thrombophlebitis and pain.
The primary therapeutic procedure for all stasis complications, except malignant degeneration, is to normalize the
underlying pathologic physiology that gives rise to cuticular
venous hypertension (which is characterized by increased
interstitial fluid and resultant reduced oxygenation and defective nutrition of the skin). This may be accomplished through
the treatment of the superficial and/or deep venous systems
and their conduits (perforator veins).
Deep venous hypertension is usually managed with conservative compression therapy. In selected patients, vein valve
transplantation or repair can also be efficacious. However,
surgeons are understandably loath to operate through eczematous skin that may be contaminated with bacteria. Thus,
dermatologic treatment is extremely important in providing
the optimal operative field. Alternatively, direct sclerotherapy
of an underlying incompetent perforating vein through the
ulcer may be performed. Sclerotherapy in this setting has been
shown to markedly enhance ulcer healing.
techniques of perforating vein interruption using endoscopic
visualization or thermocoagulation via intravascular radiofrequency or lasers, or duplex-guided foam sclerotherapy, can
also normalize venous hypertension. Finally, it is becoming
more apparent that treating the incompetent superficial
venous system with either surgical intervention or sclerother-
1
This suggests that the erect stance
3,4
Newer surgical
apy is also beneficial in restoring and/or improving competence of the deep venous system.
5–10
Historical Aspects of Treatment
Varicose veins have obviously been a problem for a long time.
Egyptian papyrus scrolls have been found that contain instructions for the treatment of leg disorders, and Ebers, in his
papyrus of 1550
formed on varicose veins.
varicose veins, in common with most physical diseases, consisted of making offerings to the gods for help, and this
continued for centuries, as can be seen in a votive relief
from around 400
(Asclepius; Latin: Aesculapius) (Fig. B). Physicians, however,
attempted to formulate more terrestrial treatments.
Hippocrates observed the association between varicose
veins and leg ulceration more than 2000 years ago.
humoral theory dictated bloodletting as a form of treatment
for varicose veins, and this remained the treatment of choice
into the Middle Ages. The first description of medical treatment appears in the writings of Hippocrates in the fourth
century
ing them with ‘a slender instrument of iron’ to cause thrombosis.
BC. He describes treating varicose veins by traumatiz-
13
Surgeons, too, were developing various treatments for
varicose veins. Plutarch described the first varicectomy without
anesthesia on the Roman Consul Gaius Marius (157–86
According to Dryden’s translation:
For having, as it seems, both his legs full of great
tumours, and disliking the deformity, he determined
to put himself into the hands of an operator, when,
without being tied, he stretched out one of his legs, and
slightly, without changing countenance, endured most
excessive torments in the cutting, never either flinching
or complaining; but when the surgeon went to the other,
he declined to have it done, saying, ‘I see the cure is not
worth the pain.’
Stripping and cauterization were practiced by Celsus (30 BC
to
AD 30). Antillus was the first to mention ligation of the
vessels, and, in the second century
that varicose veins be torn out with a hook. Paulus of Aegina
(circa
AD 660 in Alexandria) performed ligation and stripping
of the segments of the varicosity. However, after William
Harvey’s discovery of the true nature of circulation, surgical
removal of the affected veins was rejected because the procedure could cause complications that were more dangerous
than the disease itself. The modern history of surgical treatment began after the introduction of anesthesia and sterile
techniques in the late nineteenth century. This is reviewed in
Chapter 10.
Compression therapy was recognized very early as an
effective form of treatment (see Chapter 6). Roman soldiers
BC, advised that surgery should not be per-
BC found at the Greek Temple of Asklepios
11
The earliest method of treating
12
His
14
AD, Galen recommended
BC).
https://t.me/med1917
Introduction
Figure A Brahma bull with a varicose vein on the right posterior medial
leg. (Courtesy A. Butie MD)
Figure B According to the inscription, this tablet found on the west side of
the Acropolis in Athens was dedicated to Dr Amynos by Lysimachidis of
Archarnes. This represents the earliest known depiction of varicose veins
from the end of the fourth century BC. (From National Archaeological Museum of
Greece.)
wrapped their legs in leather straps to minimize leg fatigue
during long marches. Marianus Sanctus Barolitanus (1555),
Pare Johnson (1678) and de Marque (1618) recommended
the use of plaster bandages. Firm support was not widely used
until Wiseman (1676) introduced the laced leather stocking
x
for treating ulcers associated with varicose veins.15 Although
compression therapy may be quite effective for patients with
limited venous disease,
a high rate of ulcer recurrence.
16
when used alone it is associated with
17
This association may be
related to the expertise of the medical practitioner applying
compression and to the materials used. To be effective, a
compression bandage must generate 40 to 70 mmHg.18 This
means that the toes of a correctly bandaged leg must become
slightly cyanotic when the leg is horizontal and return to
a pink color on standing. Obviously, skill and experience
are a prerequisite for proper compression treatment (see
Chapter 6).
The first use of an intravenous injection in humans is attributed to Sigismund Eisholtz (1623–1688). He used an enema
syringe to inject distilled plantain water into a branch of the
crural vein to irrigate an ulcer with a small siphon.
D. Zollikofer of St. Gallen, Switzerland, reported on the injection of an acid into a vein to create a thrombus.
19
In 1682,
19
This was
the first attempt at ‘sclerotherapy’, a term derived from the
Greek word for ‘hard’, and made popular by H. I. Biegeleisen
in 1937.
20
Extravascular sclerotherapy of a hemangioma was first
reported in 1836. The surgeon, Mr. Loyd, injected from three
to six drops of nitric acid dissolved in a drachm of water. This
solution was ‘thrown into the tumour by means of a syringe
through a minute puncture at its base’.
made of the outcome of this treatment, but the next reported
case was instantly fatal.
22
21
No mention was
Intravascular sclerotherapy of an arterial malformation to
produce a clot was first performed in 1840, on animals, by
Pravaz with a solution of absolute alcohol.
tion of ferric chloride was used to sclerose varicose veins.
23
In 1851, a solu-
24
This was made possible through modification of the syringe
with the invention of a sharpened hollow needle capable of
direct venous puncture.
25
In 1854, Desgranges reported the
cure of 16 cases of varicose veins with the injection of a
mixture of 5 g iodine and 45 g tannin in 50 ml of water.26
Desgranges noted that this solution produced far fewer local
reactions than did ferric chloride. His patients were kept in
bed for 10 to 12 days. Unfortunately, extended use of this
solution and technique produced septic complications.
These intravascular sclerotherapy treatments were stimu-
lated by Rynd’s introduction of the hypodermic syringe in
27,28
1845.
Both the syringe of Rynd, an elaborate trocar and
cannula, and the subsequently modified syringe of Pravaz
were modifications of the lacrimal syringe developed by Anel
in 1713.
29
It is interesting that the apparatus manufactured for
Pravaz was unsatisfactory, because when blood and coagulantsclerosant mixed after the trocar had been withdrawn and the
syringe was screwed on, blood clotted within the lumen of the
cannula.
30
It was not until Wulfing Luer in Germany adopted
the hollow needle onto a Ferguson syringe that a device
approaching the modern syringe was used.
Between 1904 and 1910, P. Scharf used sublimate on
himself and 90 patients with varicose veins.
31
Nathan Brann,
founder of the first phlebology society, also recommended
vein sclerosis with sublimate, which produced firm thrombosis of varicose veins.
32
The foundation of modern sclerotherapy treatment of
varicose veins began in 1916 when Linser reported many
successful treatments using perchloride of mercury with an
intravascular technique.
33
He emphasized ambulatory treatments limiting the maximal dose of sublimate to 1–2 ml per
treatment session. He also inadvertently encouraged walking
after treatment, noting that many ‘women had to walk for
longer periods to their houses after treatment.’
34
However, 1%
to 3% of patients developed mercury intoxication with nephritis, stomatitis and enteritis, and the procedure again was aban-
35
doned.
Luargol solution used in the treatment of syphilis.
In 1916, Sicard noticed the sclerosing effect of
36
He
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